Tuesday, 23 July 2013

Guest blog: I believe in diagnosis but the DSM is just a door-stop

Over the last few
months we’ve regularly featured pieces taking a critical line on the new
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and on psychiatric
diagnosis more generally. We are nonetheless committed to offering a range of
views on mental health. Today we feature an article taking a more pro-diagnosis
position and offering a (possibly surprising) view on why the DSM is not always
relevant to the consideration of distress. The author, Alex Langford, is a psychiatrist with clear views on both the value
of diagnosis and the limits of classification schemes. What do you make of what
he has to say? Alex has agreed to respond to comments over the next few days.

Is the nature of most mental health problems obvious?Illustration: catcher0frye

The heat from the release of the “psychiatric Bible” (DSM-5) is thankfully simmering down. In recent months, you couldn't throw a metaphorical brick on Twitter without hitting someone who had
a strong opinion and wasn't shy of sharing it. I found this debate stimulating,
frustrating and eventually repetitive. Rarely however, did I find it clinically
relevant.

There may be a number of reasons for this. For one thing,
DSM-5 is an American book; we use a different classification (ICD-10) here in Britain. Also, I currently work in
an area of psychiatry that deals heavily with an illness that DSM doesn’t have
a definitive role in, namely dementia. But mostly, I wasn’t too bothered
because, to the probable surprise of non-medics and the public, most
psychiatrists don’t really care about the finer points of classification.

It’s not that psychiatrists don’t believe in the merits of
diagnosis. Both I, and the vast majority of colleagues I've encountered, see
large benefits in labelling people. I think it provides a useful conceptual
framework, a way of thinking about someone, helping someone, and researching
common types of suffering. And it’s not that I and many colleagues are quacks,
giving whatever wild and personally favoured diagnosis we feel like, without
thought for inter-rater reliability. I’m aware of the controversies about
diagnosis, and the harms that it causes when we get it wrong. However, these
are not the reason why many psychiatrists don’t have a large amount of time for
DSM.

No, the reason it doesn't get much attention from us is
because most diagnoses are pretty clear. Patients usually fit quite neatly into
the large, intuitive boxes for mental distress that we’ve already had for
years. If you’re really unhappy, we call it depression. If you’re really happy,
we call it mania. If you’re hearing voices, are paranoid and believe utterly
strange things, we call it schizophrenia. These are the broad descriptions that
we see standing out in our patients, and it’s these that we use in our day to
day careers. Whatever tweaks are made to the classification of things like
depression aren’t going to change anything. Really sad people will still be
depressed.

The small print doesn’t seem useful to us a lot of the
time. ICD-10 states that to have a moderate depressive episode, you need
to have at least two key symptoms (low mood, loss of interest and enjoyment,
and increased fatigability) plus at least three other symptoms (loss of
appetite, poor sleep etc) but to have a severe depressive episode, you
must have all three key symptoms and at least four others.

This clearly isn't how depression works in the real world,
and psychiatrists, who are more interested in the amount of suffering than the
number of symptoms, recognise this. If a patient feels so bad they might try to
kill themselves, they’re admitted to hospital whether the book says “moderate”
or “severe”. If they’re suffering so much they might lose their friends or
marriage, we’d advise an antidepressant regardless of their ICD-10 code. This
is a very different thing, however, to arguing that a diagnosis is useless and
unreliable, or that depression isn't “real".

The endless media reports of psychiatrists
‘labelling grief as mental illness’ were frustrating for me. I think the Daily
Mail believes we’ve started picketing funeral homes, with anti-depressants in
hand. The truth of the matter is that the expanded definition of depression
(which makes it possible to diagnose depression within 2 months of the loss of
a loved one) changes nothing in our clinical practice. If you were suffering
enough to need drugs before, you still will be. GPs won’t suddenly send us vast
swathes of bewildered people who now fit slightly inside DSM criteria for
treatment.

Being less reliant on strict classification has both good
and bad consequences. It allows us to cast aside our textbooks to see the
person, while still maintaining a workable overarching structure with which to
conceptualise their distress. It hopefully makes things more personable for the
patient, who is told he has bipolar disorder and he’s currently manic, not that
he has ‘F31.1: Bipolar affective disorder, current episode manic without
psychotic symptoms’.

DSM's pivotal role in psychiatry?Photo: John McGowan

But we don’t use this simple, loose method of diagnosing
all the time. Many specialist services, who deal with problems like autism and
ADHD find it useful to stick closely to the classification, usually because it
is well grounded in research and useful in deciding whether someone truly does
have the disorder or not. Likewise, researchers will classify their
participants tightly, so we can all tell who they've been studying.

And yes, sometimes flicking through ICD-10 has helped me.
I remember one young man who puzzled with his strange behaviour, which included
barking at the moon with a bowl on his head and describing the vibrations in
parts of his brain. Despite his actions, he seemed quite attached to reality.
It wasn't until I reacquainted myself with the criteria for schizotypal
personality disorder that I began to understand him better.

So, although the finer points of diagnostic classification
can be useful, the vast majority of the time psychiatrists have far more
pressing concerns than which subgroup of a subgroup someone falls into, like
how bad someone is feeling and whether they need help.

The fact that the public thinks we sit in our offices,
thumbing through DSM, ticking off symptoms to reach a diagnosis, is both
hilarious and worrying.

ICD-10s are propping open doors, steadying wonky tables
and gathering fine coverings of dust worldwide. The assertion that we’re devoted
to these tomes as our ‘Bibles’ is just plain nonsense.

24 comments:

I am not against diagnosis per se; I can see that for some clients receiving a label is helpful, perhaps even reassuring. However I take issue with the way in which the author suggests treating difficult human experiences.

“It hopefully makes things more personable for the patient, who is told he has bipolar disorder and he’s currently manic, not that he has ‘F31.1: Bipolar affective disorder, current episode manic without psychotic symptoms’.”

I wonder how telling someone that they have bipolar disorder and are currently manic is more personable. I struggle to see anything idiosyncratic about this. Wouldn’t ‘making things more personable’ be looking at why they’ve come to develop such difficulties and how this affects their life? What is their story, what life experiences have they had leading up to this diagnosis, how do they feel about receiving a diagnosis, how would they like to manage their difficulties? We need to be empowering clients to tackle their issues with increased knowledge and confidence, not relaying the message that the answer is medication, which is to say that their 'problems' are out of their control.

“If a patient feels so bad they might try to kill themselves, they’re admitted to hospital whether the book says “moderate” or “severe”. If they’re suffering so much they might lose their friends or marriage, we’d advise an antidepressant regardless of their ICD-10 code.”

This way of treating difficulties seems mindless – it demonstrates the way in which psychiatry pigeonholes people, or ‘fit[s them] quite neatly into the large, intuitive boxes’ as the author states. If someone is feeling suicidal, do we not need to understand why? I don’t believe that hospitalising someone simply because they are suicidal is necessary. By doing so we are giving the person the message that this is abnormal and that they cannot manage it without being admitted. How disempowering is that?

The problem with psychiatry (at least as the author describes it) is that it is missing the understanding; it has no interest in the whys and the hows, and can ultimately lead to clients feeling that it has no interest in them.

Alex your take is somewhat naive. Care Clusters are diagnosis by numbers with a sliding scale of severity with value judgements attached to each implied diagnosis within the cluster regarding 'responsibility', 'control' and biology. Come off it, we all know the hierarchy of diagnosis. A psychologist friend is now required by managers to make a diagnosis on 1st meeting a user and this serves administrative and financial procedures and structures. The accessing of social supports and 'proving' need/disability are also dependent on them it's like the raspberry sauce of a raspberry ripple ice cream, we can't unfortunately easily remove it. Therefore as much as I want to envisage a post-ICD/DSM/Crunchy Nut Cluster world, I'm realistic enough to know this won't happen quickly because psychiatry and diagnostic systems do not exist in a vacuum, we would have make many societal and political changes in tandem. We cannot ignore the damage diagnoses can cause people, I've listened to someone defined as PD state that this was worse and more invalidating than forced ECT, and likewise psychosis resulting in diagnostic overshadowing. The drugs prescribed in the name of psychiatric diagnosis have serious physical health consequences which are no longer acceptable given the weight of evidence against their 'efficacy'.

Diagnoses hide trauma and abuse. I think it's unethical when victims of incest and maltreatment during their childhood, after having survived years of horrible events are being labelled for example "borderline", and are described as being manipulative and having zero empathy by professionals instead of meeting compassion and being helped with their trauma. The only persons satisfied with the labelling is the perpetrator (often the father, sometimes both parents).

Agreed Sigrun, I've witnessed that, it's one of the most profound abuses of psychiatry to denigrate a person's entire personality as 'flawed'.

How we view people according to diagnosis is so deeply ingrained we’re almost unaware of it. Even when rhetoric claims no we have nice fluffy views scratch beneath the surface and it isn’t. Prof’s often claim to not use diagnosis but how they frame discussion clearly indicates otherwise. We can change names psychiatric nurse/service to mental health, Schizophrenia to psychosis but has the thinking behind the name changed?

I'm one of those services users (hate that name) who doesn't fit the box - lurching from one diagnosis to the next. Think they have got it correct now but the real struggle for the mental health services was that the care pathway was meant to match the diagnosis so unless you work in a different organisation how do you manage without a proper diagnosis? The trouble with pathways of course is that if you go down the wrong one you don't get better which is always your fault anyway. So many times I ended up bouncing back up the pathway to square one going 'this isn't working'.

Regards, the comment about depressed and suicidal = hospital stay - dream on, there aren't enough beds available for that anymore.

Alex, so it seems that we have a system where diagnosis is based on presentation of symptoms, if I'm correct? The diagnosis then implicates what treatment is appropriate for those particular symptoms. However, I think that psychiatrists need to be clear more about what diagnosis means. It seems that schizophrenia, bipolar and depression are describing a presentation of symptoms only as there has been no conclusive evidence about underlying causes, other than adverse early experiences, which seem to correlate with all psychiatric diagnoses. I believe that sometimes it is helpful to treat the symptoms in the short term, and that we could not do this without some system of categorisation. However, I view this as only the beginning, and I believe that it can be extremely damaging to pretend that the diagnosis defines or explains a person's distress. Although for something like dementia where there is more of an identifiable disease with a physical cause, this makes far more sense.

Writing this piece was quite formative for me; I’m still learning how to write for an audience and in truth I’m still forming my opinions on the issues I discussed. I don’t like to stick to an opinion against any and all evidence, I prefer to maintain a distance from things and be ready to change my mind.

I will address the comments posted so far now, and will address any additional comments in 2 days time. After that I’ll have to let it be.

From reading the comments as a whole, I have to say that I think the basic message of the piece has been misinterpreted by some. This is not a piece about how great diagnosis is. It’s a piece about how, in reality, making small changes to a classification like DSM makes very little impact on how we diagnose and treat people in the real world, and how a lot of the time we don’t need to go anywhere near our dusty copies of DSM to make a diagnosis.

Rosie: I am sorry if the post came across as advocating tablets for all unhappiness. This certainly isn’t the way I or the majority of my colleagues think. I used the example of needing tablets at a certain level of unhappiness regardless of what a classification would say to make a point, but the same point could equally be applied to therapy, a referral to an OT, or an admission to hospital.

Ceri: You’ve pointed out something important that I hadn’t made clear, thank you. Just because we diagnose someone doesn’t mean that the diagnosis is “the cause” of their problems, and it doesn’t mean we shouldn’t look long and hard at the precipitating factors in their situation. A diagnosis does not preclude this in any way, and to ignore it is awful psychiatry. My point was that by not adhering so closely to something like DSM, by keeping things less formal, we can move further away from a restrictive terminology and allow the meaning of the patient’s experiences to come through a little easier. To be told you have “F31.1” really must be belittling, but to be “manic” (which some people truly are, believe me) allows more room for meaning while still being useful to a psychiatrist who has a framework to use. As for the suicideadmission example, you’re right, it was simplistic. But I hope the point was clear; if you’re really unwell, you’re getting help from us regardless of what DSM says.

First “anonymous” and Sigrun: You feel passionately about diagnosis being harmful, it’s clear, and your opinions resonate with me completely. But I’m not sure your critique pertains to this post. As I stated above, I’m not lobbying for diagnosis, I’m just saying that the way we use it in real life isn’t as dependent on DSM as people may think. Psychiatrists don’t just sit down with DSM, ticking off symptoms, but are really interested in how their patients came to be so distressed. This post actually may be a good thing for your cause; particularly paragraphs 5, 6 and 7. I will defend diagnosis, and say that it’s a good thing, but it can be very harmful if it’s used as a tool for belittlement and reduction, or overvalued by number-crunchers.

Second “anonymous”: I dislike “service user” too, as do the vast majority of psychiatrists and apparently, the majority of “service users”, but I’ll use whatever makes a particular person comfortable! Your point is a good one, that sometimes diagnosis can be more tricky than usual. Some people really don’t fit into those big, intuitive boxes I mentioned. It isn’t a perfect system and I do think there has to be room to help people more flexibly than simply based on a diagnosis. You too point out my simplistic example of needing to be admitted for suicidality. I agree with you.

Becky: A lovely point and I agree with you. Diagnosis can work, but only if we are honest about what it means. It does not mean an underlying biochemical event is the cause of all the problems. To me, a diagnosis is a label we give for a certain type of stereotypical mental reaction. It doesn’t imply cause. I’ve been depressed, and I never thought I had a brain disease, but it helped to know that others had felt the same kind of awful, and because we’d be lumped into a group called “depression”, people had found out what helped. Forgetting that diagnosis doesn’t mean “brain disease” can lead to a whole lot of harm.

It is positive to hear that psychiatrists are taking a more 'real world' perspective and not adhering too rigidly to diagnostic criteria (although not all services will be as flexible as this). However I (and I'm sure others) take some issue with your view that 'Most diagnoses are pretty clear. Patients usually fit quite neatly into the large, intuitive boxes for mental distress that we’ve already had for years.', Some diagnoses have very questionable validity and views on what constitutes mental illness are quite related to culutral context and have changes a lot over the years. Some of the broad 'boxes' you describe such as schizophrenia house a large variety of people, many of whom will have very little in common in terms of their experiences, but sharing a label. You mention that ICD-10 helped you to understand your barking man, I'd be interested in hear what it helped you to understand about him? As other commenters have mentioned, seeing that someone fits the criteria for a label isn't the same as gaining understanding of their experience and what has lead them to the difficulties they are now facing.

Hi, I've been involved in the editing and posting of Alex's article. It has seemed important for us to have something going somewhat against our usual editorial line (usually quite questioning of diagnosis) and we're glad to have such a well written piece. I think it's a very honest account of working practices. I also think it scores very well (for me) by not making the increasingly common case that drugs target specific biological imbalances. It's much more (and I hope I'm not extrapolating too far here) Joanna Moncrieff position of drugs having general effects and sometimes those being beneficial. I think it's also worth saying that I think it describes a genuine and humane attempt to get beyond a kind of laundry list approach and connect a bit with the person in the room.

I do have some disagreements and concerns about the approach described too though. Most of these have been touched on above. There is the issue of locating the problem inside the individual as an illness and the logical response being drugs (or possibly psychotherapy). This strikes me as a limiting stance in response to human distress which might sometimes be better conceptualised of in terms of social circumstances or emotional trauma. (I think Ceri Jones and to an extent Sigrun have touched on this). The view of distress purely though the lens of illness and wellness has a number of profound implications not least the potentially devastating consequences of a label for the person's view of themselves. Also the way they are viewed. I know diagnostic labels can sometimes be helpful too but many, many people a different experience. (see our post on the limitations of the Time to Change Campaign). I suppose my deepest concern though is the freedom with which we all (and not just Alex and other psychiatrists talk about and apply such labels and their lack of validity. I think this is well addressed in the comment from Becky. There are huge questions over the validity of the labels in psychiatric classification schemes. The National Institute of Mental Health in the States have stopped sponsoring research in DSM categories due to a lack of biological coherence underlying the categories. There is also work (I think Richard Bentall is a good example) suggesting that the categories themselves are seriously flawed as cogent clusters of symptoms.

You’re quite right, some people don’t seem to fit very well into the intuitive boxes we have. Some seem to have symptoms from all sorts of conditions, and end up being bounced from service to service. This isn’t good, and we need to be more ready to help people like this; less diagnosis-centric, while still realising that diagnosis can often be helpful.

But this post was about how the majority of the time, people do fit into the boxes we have, and psychiatrists don’t have to go counting symptoms in DSM to confirm it.

Some diagnoses are of questionable validity, and some new ones (like DMDD) seem farcical to me. But again, I do feel that the majority of the time, we can tell depression from mania from anxiety from schizophrenia, without consulting DSM.

Mental illnesses are certainly culturally specific, but I’m not sure this is relevant. Anorexia is culturally specific as far as I know, but it’s pretty real and valid.

And I understood the young man better because I could see that other people had suffered in the same way before. It helped me pull together all his symptoms into one coherent story. I looked up the condition, read about how sufferers tend to feel and think, what stressors they tend to have had, and what helps make them better. He was an individual, but an individual that was suffering in a particular way.

Alex I have a lot of respect for how you've answered these comments and especially that you've put your opinion out here to spark debate - I can see where you're coming from.

I'm left with a few questions though. I don't mean this to be as rude as it might sound (it's something you could probably level at many professions) but if psychiatrists don't have to be DSM/ICD experts and if people usually fit quite generally into well-known categories (mania, psychosis, depression) that mental health professionals could easily recognise, why do we need such highly trained doctors to administer medication or, as you mention, make referrals to OT and psychotherapy? Couldn't GPs and nurse prescribers do this if it's as 'loose' as you suggest?

Perhaps it might be that we need psychiatrists expertise (and as you suggest, the DSM) to understand the more unclear presentations/diagnoses? But is it necessary for someone to have suffered the same thing as a group of other, similar people in order to understand them and their experiences? I wonder what you think about formulation which (I believe) is part of psychiatric training and attempts to explain why an individual may present in the way that they do (no matter how idiosyncratic).

I think that while psychiatrists don't intend to cause harm to their clients by providing a diagnosis, they have no power over how this will be received. While you may see it as a helpful framework as a professional, the person may experience their label(s) very differently - either in the way that they interpret its meaning for their identity, or when it comes to real-world issues like discrimination and social stigma.

Having a diagnosis unfortunately does imply that you have something wrong with you. I think your point about anorexia serves to highlight the problem John McGowan raised about locating the problem in the individual - if some conditions are culturally dependent then should we be diagnosing the culutre and not the person?

It's difficult for me to see how helpful diagnosis really is as a 'short-hand' or a framework when all of our actual work as professionals - our 'treatments' - revovle around what works for each patient.

A diagnosis can be a starting point for treatment, for researching treatment. If I developed low mood, lost my appetite, woke up early in the morning, then yes, I may meet diagnostic criteria for depression. If I were to seek Alex's help, he'd probably tell me I am depressed but he is a personable chap and I suspect he'd also ask about what may have led up to the depression (a bereavement, stressful life events, loss of a job, out of the blue, something else?)

Without a diagnostic category to give us some order and structure, we would not be able to research therapies (medical, psychological or otherwise) and we wouldn't know how best to help someone.

As it is, Alex would have a host of research into depression at his fingertips and could advise me that any of the following may help:

-antidepressants-most psychological therapies and not a great deal of difference between them -mindfulness for relapse prevention if this isn't my first episode and I'm not currently depressed

If Alex had also deduced that my depression was linked with loss of a job, he could refer me on for vocational support or if a bereavement, he could direct me to CRUSE or another source of bereavement support.

Diagnosis is a tool and like a hammer, you can use it productively or you can use it to beat someone over the head. It's about the hands it is used in and the skill with which it is used.

I don't usually get involved with diagnosis. Psychiatrists are far better trained in that that I am but it is certainly part of my assessment as a clinical psychologist to find out what my psychiatry colleagues think and it can be part of a broader understanding of someone's difficulties.

Also, most people with mental health problems don't ever reach a psychiatrist. They'll see their GP or their practice nurse and be referred for psychological support, offered medication and directed to local supportive services in primary care. Psychiatrists really only see people with more complex and challenging difficulties where their level of training and expertise is invaluable.

I'm really pleased to see the CCCU AP hosting a voice from 'the other side', thanks for doing this, and thanks to Alex for posting.

As a service user who finds (in my own case) diagnosis helpful, I wanted to respond to John's comments (thanks for the editing work). Firstly, I'd be surprised if Alex subscribed to the Moncrieff view of medication, I'll be interested to see. Secondly, yes validity in diagnosis is contested, but I'm always interested in what less-contested replacement is being proposed for diagnosis here and now. (The BPS alternative to diagnosis, at least according to the position statement, is still very much on the drawing board, ditto Bentall's 'complaints' and Kinderman's 'problems'.) Thirdly, I wouldn't say (again, in my case) that diagnosis was disempowering (I know it is for some people).

For me, diagnosis (echoing Clinical Psychologist & Friend of Psychiatrists) is more empowering than just calling it "distress". If I was just labelled "distressed", I couldn't find research relevant to my problems, and I couldn't draw on all the knowledge that other people have acquired, through lived-experience. It would also be the end of medication, which I find helpful. So replacing diagnosis with "distressed", in my case, would be radically disempowering.

I found this post both illuminating and rather depressing. I don't doubt Alex Langford's sincerity and he seems to think about his patients compassionately. That said, I believe there are huge dangers in thinking about human distress in this way, and I believe it is ultimately profoundly damaging. There are huge numbers of people who fall between the cracks and do not 'intuitively fit into categories'. Even if (for sake of debate) we accept the idea that a classificatory system is necessary and that mental illness can be quantified, we would need to concede that human distress occurs on a continuum rather than falling into neat categories. And even if we waived aside issues concerning validity (again for the sake of debate), we would have to acknowledge that the DSM categories do not refer to discrete entities but in fact 'shade' into one another. The nature of distress also changes through time which would account in part, for the reason why so many people collect a large variety of labels. Indeed, where psychological intervention is successful, we would expect the nature of their distress to change over time and sometimes to ameliorate. There are also naive assumptions being made, I think, that identifying and labelling the distress somehow defines it (issues that have been eloquently brought to bear by other commentators on this page).

If psychiatrists are diagnosing patients intuitively, as Alex suggests, this flags up numerous issues pertaining to reliability, let alone those concerning the validity of the DSM diagnoses themselves. A system of diagnostic classification could only be worth having if it provided adequate inter-rater reliability. If its really as intuitive as Alex suggests, then it is really not worth having from any point of view, either scientific or humane.

While I realise that it wasn't the focus of this article, psychiatrists also do not seem to have answers as to what should happen if someone recovers but finds themselves stuck with a label that is both hindering and defamatory of them. Many psychiatrists have no problem in telling their patients at the time of diagnosis that their difficulties will be lifelong and that they will always need medication. Fortunately, this is not always the case and people recover - even from serious 'mental illness' and not necessarily infrequently. Sadly, a vocabulary of recovery does not appear to be built into the lexicon of those psychiatrists who are very biologically oriented, however. I can only conclude that we have a very long way to go in adequately getting to grips with these problems as a human community. To imply that it is not only possible to neatly sew them these issues, (or indeed to suggest that the 'intuitive boxing' methods of psychiatrists have already done so) seems dangerously naive.

Okay, let’s respond to the few remaining comments. After that I’m afraid I can’t promise I’ll have the time to check the page again.

John: I do hope the piece brings across the fact that real psychiatry isn’t like making a laundry list, and I’m glad you felt that it did that. The rest of your comments touch on genuine issues to do with the faults of diagnosis, but I’d like to reiterate that this piece wasn’t a rally for diagnosis; it was just a descriptive piece about how diagnosis is used in the real world.

I would hope though, that at no point did I insinuate that I think that a diagnosis locates the problem in the individual and advocates only medication as treatment. Apologies if the simple treatment examples I used were about drugs, I could’ve used anything.

When one looks at diagnoses like PTSD, one hopefully sees how a diagnosis is most usefully used, and how a good psychiatrist will use any diagnosis. It’s a label, true, but it’s a label that literally acknowledges that the problem involves the environment. To be honest, medical diagnoses don’t locate the problem solely in the individual. The reaction is always in the individual, of course, but the cause isn’t. Childhood asthma is no less of a diagnosis because you get it from inhaling a load of smoke at home because your mother refuses to quit. You can usefully treat it by modifying the environment or the child, or hopefully both.

I don’t have the strength to pick apart the validity of certain diagnostic categories tonight. I know the research suggests they aren’t great, that they perhaps represent the peaks in the mountain rage of mental distress rather than discrete entities, but I will say that in my practice, the majority do fit rather well into the big boxes we have. I’m all for increasing the validity of diagnostic categories though.

As for Moncrieff: I like her message, which is that we should be thinking about the side effect and qualia profile of drugs when we prescribe them, and not thinking of them linearly as illness-treatment pairs. But I think her assertions that drugs just augment “normal biochemical states” and are entirely non-specific is, in the modern world of research, plain daft. It’s not as simple as the serotonin/dopamine hypothesis, but come on, it’s not “normal” either. In fact, I saw her lecture to a hall of psychology students, and she was so vitriolic and biased in her critique of psychiatry, she turned the entire room vehemently against psychiatry, probably for life. This angered me.

Anonymous at 21:14: You’ve answered most of your own questions. We need psychiatrists to deal with complex cases, and do everything past the (sometimes) relatively simple diagnosis.

I like formulation, I have no idea why people think psychiatrists don’t. It’s as vital as diagnosis, we do both all the time. They’re like flesh and bone: try having one without the other.

Diagnosis does imply that there is something wrong with someone, and to a degree, that is actually right. If I was hit by a car and broke my leg, I’d certainly have something wrong with me. But no one would think that it was something intrinsic to me. The external causation needs to be acknowledged more by us in psychiatry.

Angela: Hopefully some of your points will already have been answered.

I said in the piece that *most* diagnoses are clear. Indeed some are not, and people fall through the cracks, suffering. Personally I think there’s plenty of room to tighten up the diagnostic system we have. However, I will stand by the notion that the basic categories are identifiable in practice in the majority of cases and “intuitive diagnosis” isn’t as haphazard as it sounds. We just see so many cases that clearly fall into a distinct group, we don’t need to check DSM.

We could probably be more pro-active in removing labels from people too, as you say.

But I really dislike the idea of getting rid of diagnosis altogether; terrible. Losing a nomethetic structure would be the end of the road for research and deny both the severity of our patient’s suffering and the undeniably reasonably structured nature of mental illness.

It would be like burning down your house because you didn’t like the wallpaper.

HI Alex, Oddly enough I received it in an email saying it had been posted. Germlins in the works and perhaps it will come up later. I seem to remember it contained a kind remark about Joanna Moncrieff. Maybe that's just going through some extra checks?

Okay, let’s respond to the few remaining comments. After that I’m afraid I can’t promise I’ll have the time to check the page again.

John: I do hope the piece brings across the fact that real psychiatry isn’t like making a laundry list, and I’m glad you felt that it did that. The rest of your comments touch on genuine issues to do with the faults of diagnosis, but I’d like to reiterate that this piece wasn’t a rally for diagnosis; it was just a descriptive piece about how diagnosis is used in the real world.

I would hope though, that at no point did I insinuate that I think that a diagnosis locates the problem in the individual and advocates only medication as treatment. Apologies if the simple treatment examples I used were about drugs, I could’ve used anything.

When one looks at diagnoses like PTSD, one hopefully sees how a diagnosis is most usefully used, and how a good psychiatrist will use any diagnosis. It’s a label, true, but it’s a label that literally acknowledges that the problem involves the environment. To be honest, medical diagnoses don’t locate the problem solely in the individual. The reaction is always in the individual, of course, but the cause isn’t. Childhood asthma is no less of a diagnosis because you get it from inhaling a load of smoke at home because your mother refuses to quit. You can usefully treat it by modifying the environment or the child, or hopefully both.

I don’t have the strength to pick apart the validity of certain diagnostic categories tonight. I know the research suggests they aren’t great, that they perhaps represent the peaks in the mountain rage of mental distress rather than discrete entities, but I will say that in my practice, the majority do fit rather well into the big boxes we have. I’m all for increasing the validity of diagnostic categories though.

As for Moncrieff: I like her message, which is that we should be thinking about the side effect and qualia profile of drugs when we prescribe them, and not thinking of them linearly as illness-treatment pairs. But I think her assertions that drugs just augment “normal biochemical states” and are entirely non-specific is, in the modern world of research, plain daft. It’s not as simple as the serotonin/dopamine hypothesis, but come on, it’s not “normal” either. In fact, I saw her lecture to a hall of psychology students, and she was so vitriolic and biased in her critique of psychiatry, she turned the entire room vehemently against psychiatry, probably for life. This angered me.

About the Salomons Centre

The Salomons Centre for Applied Psychology in Tunbridge Wells, England. We are part of the Canterbury Christ church University Department of Psychology, Politics and Sociology. We run training courses in Clinical Psychology and CBT and also practice improvement programmes for child and adolescent mental health services. On this site staff and trainees in the Department write about a wide range of issues related to applied psychology, psychological therapies, policy and health service development.